A comprehensive review has provided best approaches for the diagnosis and management of pericarditis.
Investigators analyzed 53 articles, including 21 observational studies, 15 clinical trials, 9 narrative reviews, 4 multicenter registries, 2 guidelines, 1 systematic review, and 1 basic science study, according to the review in JAMA.
Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. Acute pericarditis is diagnosed when at least 2 of 4 criteria are present: characteristic chest pain (≈ 90% of cases), new widespread ST-segment elevation and PR depression on electrocardiogram (ECG) (25% to 50%), new or worsening pericardial effusion (≈ 60%), or a pericardial friction rub (< 30%).
In North America and Western Europe, idiopathic or viral causes are most common, followed by post-cardiac injury syndrome. Tuberculosis remains the leading cause in endemic areas, accounting for 65% to 70% of pericardial effusions in Africa.
Management of pericarditis follows a stepwise approach. First-line therapy for acute idiopathic pericarditis includes high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine. The ICAP study demonstrated that a 3-month course of colchicine reduced the risk of recurrence from 37.5% to 16.7%.
Recurrence was reported in 15% to 30% of patients after initial treatment. Among these cases, continuing colchicine for at least 6 months is recommended. The CORP study of first recurrence showed that colchicine reduced subsequent recurrence from 55% to 24%.
Among patients with multiple recurrences resistant to NSAIDs and colchicine, interleukin (IL)-1 blockers have shown efficacy in randomized trials. The RHAPSODY trial reported that rilonacept reduced recurrence from 74.2% to 6.7% in patients with multiple recurrences.
Laboratory assessment reveals elevated C-reactive protein (CRP) levels in 78% of acute pericarditis cases. Imaging plays a key role, with echocardiography recommended in all patients with suspected acute pericarditis. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) is useful in assessing inflammation severity in recurrent cases.
Several factors may influence prognosis and recurrence risk. Underlying autoimmune disease is associated with a 50% increased risk of recurrence. Persistently elevated CRP levels after 1 week of therapy indicate higher recurrence risk. Significant pericardial LGE on CMR is associated with a 40% higher recurrence risk.
Complications of pericarditis include constrictive pericarditis, which develops in less than 0.5% of patients with acute idiopathic pericarditis, whereas pericardial tamponade occurs in less than 3%. For specific etiologies, constrictive pericarditis occurs in approximately 33% of bacterial pericarditis cases and 20% of tuberculous pericarditis cases.
The review also reported on pericarditis in systemic autoimmune diseases, noting that it may occur in up to 20% of patients with systemic lupus erythematosus. In rheumatoid arthritis, 30% to 50% of patients may have asymptomatic pericardial effusions.
Post-cardiac injury syndrome is reported to occur in 4% to 5% of patients following myocardial infarction, approximately 10% following ablation for atrial fibrillation, and 20% to 30% following cardiac surgery.
The authors reported receiving grants and personal fees from pharmaceutical companies, including Novartis, Kiniksa, Sobi, CardiolRx Therapeutics, and Pfizer as well as serving on scientific advisory boards for some of these companies, all outside the submitted work.